5.29 School-based interventions

Last updated: January 2023

Suggested citation: Hanley-Jones, S, Letcher, T and Wood L. 5.29 School-based interventions. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2023. Available from https://www.tobaccoinaustralia.org.au/chapter-5-uptake/5-29-school-based-interventions

 

School-based interventions have been the traditional cornerstone of efforts to prevent the adoption by young people of unhealthy behaviours including smoking.1 Some of the major premises underlying the use of schools to promote health include the following:

  • Children spend a large proportion of their time in school, including during the developmental years when health-risk behaviours are often formed.
  • Schools are recognised places of learning, and have structures and systems into which ‘health education’ can be integrated.
  • The school environment, and the messages and cues it communicates, can influence student attitudes and behaviours by either reinforcing or undermining what is taught in the classroom.
  • Schools provide a prime access point as nearly all young people attend school, including disadvantaged and ‘at risk’ groups.
  • Schools also provide access to important secondary target groups such as parents, families and the broader community.1

The most common types of school-based smoking prevention methods are described in Table 5.29.1.2 An evaluation summary of the approaches is presented in the following section.

Table 5.29.1 School-based intervention methods relating to smoking among young people

Methods

Description

Information-giving curricula 3

Present information about smoking, including health risks of tobacco use, and the prevalence and incidence of smoking.

Social theory based

Social competence curricula based on Bandura’s Social Learning Theory,4 social influence approaches based on McGuire's Persuasive Communications’ Theory,5 and Evans’s Theory of Psychological Inoculation.6 Programs may be underpinned by one or a combination of these approaches.

Multi-modal programs

 

The methods combine curricular approaches with wider initiatives within and beyond the school, including programs for parents, schools or communities and initiatives to change school policies about tobacco, or state policies about the taxation, sale, availability and use of tobacco. This is congruent with a health promoting schools approach that is considered ‘best practice’.7

Source: Thomas and Perrera 20062

5.29.1 Are school-based programs effective?

Older studies have reported mixed evidence regarding the effectiveness of school-based smoking interventions, both from individual studies and various reviews of the evidence.2, 8-11 However, few studies evaluate long-term impact,12, 13 and of those that have, the results tend to show more success.14  Several older reviews concluded that school-based smoking prevention programs were relatively ineffective.10, 12 However, a critique of these reviews argued that the differing methodologies and methodological limitations of past reviews have led to conclusions of ineffectiveness, and notes also the difficulty of strictly comparing the vast variety of programs that have been implemented in schools, which can differ considerably in theoretical framework, target age group, program content, method of delivery, duration, type of school environment and so on.11

In this comprehensive ‘review of reviews’, the researcher concluded that school-based interventions can produce significant and practical effects in both the short term and long term.11 However, the review found certain elements were critical for long-term effectiveness, including interactive social influences or social skills programs, a duration of 15 or more sessions including some up to at least ninth grade, and substantial short-term effects.11

A 2015 systematic review and meta-analysis on the effectiveness of school-based smoking prevention curricula found no effect when followed up within one year or less, however, a 12% reduction in the onset of smoking was found when assessed over a longer period of follow-up.14 When examining the types of curricula used, only social competence and combined social competence/social influence showed statistically significant results. Social competence curricula include interventions that help adolescents refuse offers to smoke by improving their general social competence and personal and social skills. This type of intervention teaches problem solving, decision making, cognitive skills to resist personal or media influences, ways to increase self-control and self-esteem, coping strategies for stress, and assertiveness skills. Information-only, social influences and multimodal curricula were not found to be effective.14

A 2021 meta-analysis of randomised controlled trials on the effects of smoking prevention programs for young adolescents found that smoking prevention programs reduced the smoking behaviour (i.e. initiation, continuation and cessation of smoking by active smokers) of young adolescents, with high-intensity (seven or more sessions) school-based programs conducted by trained instructors to be especially effective.15

Various reviews have sought to distil evidence to determine which intervention elements are associated with program effectiveness. One meta-analysis found that programs with interactive learning strategies were significantly more effective than non-interactive programs.16 Other reviews found that interventions based on social reinforcement, developmental stages and social norm orientations have been more effective in modifying attitudes and behaviour than programs that focus on more rational information delivery.13, 17, 18 Programs only providing information have limited, if any, effect2 and are generally viewed as dated and too narrow a form of health education.

The timing of interventions in relation to child age and development can also be pertinent in terms of effectiveness. Evidence suggests that the most critical window of opportunity for prevention programs in school settings appears to be in the late primary to early secondary school years.19 This corresponds to the age at which smoking experimentation is typically observed. In an intervention targeting 5th and 6th grade students, treatment had limited effects during elementary school but in secondary school (one year later) significant effects on smoking and behavioural determinants were seen.20 The intervention group had a higher intention not to smoke and started to smoke less often than the control group.20

One of the criticisms of some interventions is that they have been designed and initially piloted as ‘research projects’, which may not be so effective when implemented in ‘real life conditions’ within schools.17

There is some evidence of a synergistic effect on smoking behaviour from the dovetailing of school programs with mass media and other interventions targeting young people.21 An Australian example of this was the Western Australia Smarter than Smoking project, which had an active schools component (including teacher and school activity resources, school grants, smarter than smoking sports, arts sponsored activities for school students) complementing mass media and other strategies.22 As noted by researchers,23 it is often difficult for multimodal interventions to disentangle the relative impact of school curricula-based, school-wide environmental change, parent training, mass media and community-wide interventions.

As summarised in the US Surgeon General’s 201224 report on preventing tobacco use among youth and young adults, school-based programs are more effective when they are a part of  coordinated, multicomponent interventions that combine mass media campaigns, tax and price increases, and state-wide or community-wide changes in smokefree policies.25 A 2006 Cochrane review similarly concluded that school-based interventions that are multi-modal and complemented by broader community campaigns and strategies are more likely to be effective.2

Not only is effectiveness of school-based programs affected by the quality of the intervention content and delivery, and the degree of supporting strategies in the broader school and community, but research also suggests that other individual traits of students can affect the extent to which they are responsive to smoking prevention interventions. For instance, in a smoking prevention trial conducted in China, adolescents at risk for developing depression were found to process social information differently from low-risk peers: specifically, the program was less effective for adolescents with high levels of depressive symptoms, and their perceptions of smoking prevalence among friends was more resistant to change.26 The authors concluded that individual disposition traits need to be taken into account in developing prevention programs.26 Another study looked at the association between depressed mood and smoking uptake among a cohort of students exposed to two school-based smoking prevention interventions. Follow-up data on depressed mood and smoking were collected from the students from Grade 6 through to age 19 years. Depressed mood was found to be associated with smoking uptake.27 One’s personality has also been taken into account in developing prevention programs. PreVenture, a selective personality-targeted prevention program, has been shown to be effective in reducing the uptake of tobacco smoking in adolescence.28 The program targets adolescents who score highly on the Substance Use Risk Profile Scale, a screening tool for personality types, and helps adolescents identify how their personality may lead to certain emotional and behavioural reactions and risky coping mechanisms, and helps to develop positive health behaviours.28

It has been argued that at best, existing school-based interventions appear to be able to delay the onset of smoking,29, 30 rather than prevent it. However, two of the most comprehensive reviews of the evidence contend that some interventions have been shown to be effective in deterring smoking uptake.11, 15 Moreover, even if interventions do only delay onset, while prevention is obviously the preferred outcome, delayed onset is still a positive public health outcome because mortality is lower and quitting rates are higher among smokers who commence smoking at a later age.9, 30 One study found that an intervention that delays smoking initiation without decreasing smoking prevalence at age 18 years may reduce adult smoking prevalence by 0.13–.032% and all-cause mortality by 0.09% over the lifetime of the sample.31

5.29.2 School-based smoking interventions in Australia

All states and territories in Australia have developed, or have access to, some form of school-based smoking prevention activity (see Table 5.29.2). These programs vary in their delivery technique, content and target group, but many cover similar topics. The State Government of Victoria has had comprehensive Smoke Free Schools Tobacco Prevention and Management Guidelines for Victorian Schools in place for some time,32 and both Tasmania33 and the Northern Territory34 have highlighted the need for similar school tobacco prevention programs in their most recent tobacco action plans.  

Table 5.29.2 Examples of school-based interventions in Australia
Strategy/program Description Target group Location

The critics' choice

Encourages students to watch, critique and discuss 12 anti-smoking television advertisements from all over the world. Classroom worksheets included.

Free resource.

Upper primary and lower secondary

South Australia, New South Wales, Queensland, Western Australia, Tasmania, Victoria, the Australian Capital Territory

PreVenture

An evidence-based prevention program that uses brief, personality-focused workshops to promote mental health and delay substance use among young people.

https://preventureprogram.com/

Ages 12 to 18

New South Wales

Life Ed: On The Case

This Life Ed module builds critical literacy skills and empowers students with the knowledge & skills to make informed choices about smoking.

 

https://lifeed.org.au/modules/primary/on-the-case/

Years 5 to 6

Australia wide

Smoke Free Schools

Tobacco Prevention and

Management Guidelines

for Victorian Schools

Tobacco Prevention Education Curriculum Materials – A classroom approach for teachers designed to assist schools to become completely smoke free environments. It contains guidelines, support and classroom materials for the prevention and management of smoking tobacco.

 

https://www.education.vic.gov.au/documents/school/teachers/health/sfscurriculum.pdf

Years 5 to 9

Victoria

Strong & Deadly Futures

School-based alcohol and drug prevention program for Aboriginal and Torres Strait Islander secondary students that is culturally inclusive, incorporates cultural strengths, and focusses on empowerment of the students.

 

https://strongdeadly.org.au/

Developed for 13 to 14 year old Aboriginal and Torres Strait Islander secondary students

Queensland, New South Wales and Western Australia

Get Ready: Research-based education addressing drugs and youth

Get Ready is an evidence-based drug and alcohol education program developed by the Department of Education and Early Childhood Development, Edith Cowan University, University of Melbourne Youth Research Centre. The program is made up of 10 lessons delivered sequentially by a teacher.

 

https://positivechoices.org.au/teachers/get-ready

Year 7 to 9 students

Australia wide

Drugs & Alcohol: What you need to know

A series of booklets for students, teachers and parents funded by the Australian Government and developed by The Matilda Centre for Research in Mental Health and Substance Use at the University of Sydney; National Drug & Alcohol Research Centre at the University of New South Wales, and National Drug Research Institute at Curtin University.

https://positivechoices.org.au/teachers/drug-education-student-booklet

Year 9 to 12

Australia wide

School drug education and road aware

Teacher education, curriculum support, drug information for parents, support for school policies, support for parents and community participation in developing and implementing drug education programs, policies and protocols. Includes information on the effects of tobacco, terms and definitions relating to tobacco, patterns and prevalence of use, models to understand usage, usage by adolescents, theory and principles of intervention and strategies for responding.

All years

Western Australia

 

As noted in the literature, evaluation of school-based smoking interventions is generally patchy, and information on effectiveness is not readily available for many Australian interventions. Exceptions are interventions that have received research grant funding. An Australian study investigated the impact of the Drug Education in Victorian Schools (DEVS) program on tobacco smoking after three years and found intervention students smoked fewer cigarettes and experienced less smoking related harm, than the control groups.35 Australian research on the effectiveness of the personality-targeted prevention program PreVenture for adolescent tobacco use found students from participating schools were less likely to report recent tobacco use and intentions to use tobacco in the future over the three-year follow-up period, compared to control schools.28, 35

5.29.3 Making school-based interventions more effective

Despite some mixed evidence of effectiveness, school settings do have the potential to influence the health-related beliefs, attitudes, knowledge and behaviour of young people in relation to smoking, and are an important complement to other tobacco-control measures.

Effectiveness would be enhanced if school-based interventions were more strategically based around the evidence of factors influencing smoking uptake. For example, recognition of the importance of the social context of smoking supports programs that explore and address social influences, particularly programs that allow students to explore these issues themselves, either individually or in groups.36 School programs have effectively helped to impart awareness of the long-term health effects of smoking, but young people tend to disassociate themselves from these consequences,37 as they lack personal salience to their lives in the here and now. Focusing on the shorter term consequences of smoking is far more relevant to young people than longer term health effects,38, 39 a finding reiterated repeatedly in focus group research with adolescents in Australia.37, 40 Programs also need to be adaptable to the needs and culture of different minorities to resonate with these groups.13 Findings from the National Youth Tobacco Prevention Research Project suggest that there is potential for smoking to be incorporated into teaching as a ‘factual study’ of a social change phenomenon,37 rather than being confined to the health curriculum.

There is considerable scope also to improve the content, design and delivery of behaviourally based interventions in schools to enhance their relevance, appeal and effectiveness with young people.41, 42 Classroom-based activities and lessons need to be framed around current and evidence-based pedagogy and not outdated health education or didactic learning approaches. This is reflected in the factors identified by researchers as integral to effective school-based drug prevention programs more broadly, which seem congruent with findings regarding smoking-specific school-based programs. The effective ingredients include:43

  • interactive delivery methods
  • use of the social influence model
  • components on norms, commitment not to use, and intentions not to use
  • community components
  • use of peer leaders rather than relying totally on adult providers
  • inclusion of training and practice in the use of refusal and other life skills.

One study found considerable success in the ASSIST program, training peer supporters to undertake informal conversations about smoking with other students outside the classroom setting. Schools that were randomised to the trial intervention had lower odds of smoking at all three follow-up periods, with a significant risk reduction at one year that diminished to a non-significant reduction at two years.44 Subsequent guidelines encouraged the use of peer led interventions and the ASSIST program.45 See Section 5.28 for more on peer to peer interventions. Programs should have built-in methods of updating material,46 particularly as smoking runs the risk of being viewed as a ‘tired’ issue; innovative and creative ways to address it are important.42 Programs need to be sustained until the school leaving age through ‘booster’ components such as health fairs or guest speakers in order to retain pertinence.45, 47

Moreover, teachers and school curricula often struggle within a crowded timetable to accommodate the silo approach to health risk factors (that is to say, lessons focused on tobacco only). The UK National Institute for Health and Clinical Excellence recommends that information on the health impacts of smoking and its social, legal and behavioural aspects be integrated into the broader curriculum in areas such as biology, economics, mathematics, chemistry, geography or media studies.45 It is unhelpful to treat each health issue independently, as there are underlying determinants, issues and skills relevant across health behaviour areas. The clustering of tobacco use with other risk behaviour is well documented (see Section 5.5).9 17 48 Researchers also argue that coupling smoking with other health issues is beneficial because on its own, it is often ranked below other topics in terms of teacher priority.17 Teachers may be more prepared to devote curriculum time to more comprehensive rather than single issue programs.9

A 2017 systematic review exploring factors affecting the implementation of tobacco and substance use interventions within schools found key facilitating factors for implementation included: positive organisational climate, adequate training, and teacher's and pupils’ motivation. School contexts that matched the intervention with their own promoted values were more likely to enable successful implementation, along with training teachers and students in the appropriate instructional strategy required.49

Barriers to implementation included: heavy workloads, budget cuts and lack of resources or support. In particular, education providers within the school setting often did not fully understand the scale and complexity of the implementation requirements, which would lead to low fidelity in carrying out the intervention as intended.  Despite the small but diverse literature reviewed, the factors related to successful and limited implementation remained consistently identified throughout the study.49

5.29.4 School policies

One of the single most inexpensive actions a school can take to reduce smoking is to introduce and enforce a no-smoking policy for teachers, staff and students alike.50, 51 An analysis of smoking and policy at 55 schools demonstrated an association between policy strength, policy enforcement and the prevalence of smoking among pupils.52 In a study of factors from the school and community environment that affect smoking among young people, researchers found that students were less likely to smoke if they attended a school with a focus on tobacco prevention, stronger policies prohibiting tobacco use and fewer students smoking on the peripheries than in schools without these characteristics.53

In a 2017 review54 on the impact of school tobacco policies on adolescent smoking behaviour the researchers recommended that for school tobacco policies to be successful schools should include all buildings and premises, not allow students to leave school premises, develop clear rules, ensure strict enforcement, apply the policies to all individuals, and complement with education, prevention, and counselling. Moreover, the researchers recommended that policy should be continuously assessed for impact and adapted to incorporate improvements.54

Bans on smoking in schools need to be diligently enforced to have most impact on adolescent smoking rates.55 Strict and consistent enforcement is important as adolescents may take advantage of staff members who do not strictly enforce the smoking ban by using them as opportunities to smoke. Inconsistent enforcement by staff members may lead adolescents to perceive the smoking ban as unfair (e.g. different sanctions applied to different adolescents). Lastly, adolescents may rebel against school authority when the rules are perceived to be inconsistent.54

Due to the importance of strict and consistent enforcement of school tobacco policies, a 2019 review56 set out to understand what determines staff enforcement of school tobacco policies. The review found that staff members feel more responsible, motivated and confident to enforce school tobacco policies when they feel that the school tobacco policies are part of the school staff’s professional role and duties, feel their contribution is leading to positive outcomes, and feel that they are able to deal with students’ responses.56

In Australia, all states and territories have smokefree laws for schools indoors, however, to date, only Victoria, Queensland and the Northern Territory have smokefree laws that apply to school grounds, see Table 15.7.1 in Section 15.7.10 for more Smokefree legislation across Australian states and territories. However, Northern Territory still allows smoking in designated areas on school grounds under the proviso that it is out of sight of children.57 Western Australia’s Department of Education and Training extended its smokefree policy to all outside areas in 2005.58  

Relevant news and research

For recent news items and research on this topic, click here.Last updated June 2024)

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